Provider First Line Business Practice Location Address: 
1072 AVE MIRAMAR
    Provider Second Line Business Practice Location Address: 
ROAD 2 KM 78.5
    Provider Business Practice Location Address City Name: 
ARECIBO
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00612-2744
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-879-5248
    Provider Business Practice Location Address Fax Number: 
787-880-3307
    Provider Enumeration Date: 
09/21/2006